Lafon Nursing Facility Of The Holy Family
Inspection history, citations, penalties and survey trends for this long-term care facility in New Orleans, Louisiana.
- Location
- 6900 Chef Menteur Hwy, New Orleans, Louisiana 70126
- CMS Provider Number
- 195632
- Inspections on file
- 29
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Lafon Nursing Facility Of The Holy Family during CMS and state inspections, most recent first.
A resident receiving tube feeding did not have accurate documentation of enteral feeding administration and gastric residual volume (GRV) checks by an LPN. The LPN recorded that feedings were restarted when they were not, and failed to document subsequent GRV checks and the actual time feedings were resumed, contrary to facility policy and professional standards.
A resident with a PEG tube did not have Enhanced Barrier Precaution (EBP) signage posted as required, and staff—including an LPN and two aides—failed to wear gowns during high-contact care activities such as PEG tube care and transfers. Staff interviews revealed they were unaware of the resident's EBP status and acknowledged that proper PPE should have been used.
Two residents in semiprivate rooms did not have ceiling-suspended privacy curtains around their beds, as observed during multiple surveyor visits. Staff and the DON confirmed the absence of required privacy measures for these residents.
A resident was discharged without a completed and accepted home health referral as ordered, and without arrangements for necessary PEG tube feeding equipment and formula. The facility did not ensure the resident's discharge needs were met, resulting in delays in both home health services and delivery of essential feeding supplies.
The facility did not complete required transfer or discharge reports for three discharged residents, omitting essential information such as the reason for transfer, relevant care instructions, discharge location, and a final summary of each resident's status. The administrator confirmed that these reports were incomplete and should have been properly filled out according to facility policy.
The facility failed to post a notice of employees' rights against retaliation for reporting crimes against residents in a conspicuous location. Observations and interviews revealed that no signage was displayed in employee common areas, and staff, including an LPN, the COO, and the Compliance Executive Nurse, were unaware of the requirement. The Administrator confirmed the absence of the signage and lack of awareness of this requirement.
A facility failed to report an abuse allegation involving a resident to the State Survey Agency within the required two-hour timeframe. The incident was discovered two days after it occurred, and the report was delayed. The administrator was aware of the allegation but inaccurately documented the discovery date and time. The CNA involved was suspended pending investigation results.
The facility did not conduct a performance review for a CNA within the required 12-month period. The CNA was hired in March 2023, and the last review was documented in March 2024, with no evidence of a review in the past year. This was confirmed by the HR Director and Administrator.
A facility failed to document monthly weights for a resident, as required by the care plan and facility policy. The resident's care plan included monthly weight evaluations per the dietician's recommendations, but weights for two months were missing. The Compliance Executive Nurse confirmed the absence of documentation, which hindered the dietitian's ability to assess the resident's weight loss percentage.
A facility failed to complete and transmit a Discharge/Transfer MDS assessment for a resident who was transferred to the hospital and subsequently discharged. The absence of this assessment was confirmed by an LPN and the DON, who acknowledged the oversight.
A facility failed to ensure the accuracy of an MDS assessment for a resident. The MDS incorrectly documented the use of bedrails as a physical restraint, despite the resident being cognitively intact and not having bedrails on her bed. Interviews confirmed the error, and the DON indicated that the facility did not use restraints.
The facility did not conduct annual performance evaluations for two CNAs and a Receptionist, as required. Despite being hired well before the survey, there was no documented evidence of these evaluations. This was confirmed by the HR Director and Director of Operations.
The facility failed to ensure safe mechanical lift practices, resulting in a resident's injury when a sling strap broke during a transfer. Another resident was transferred using a sling with altered straps, despite staff acknowledging the defect. These actions violated the facility's policy to discard defective slings.
Failure to Accurately Document Enteral Feeding and Residual Checks
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident receiving enteral nutrition via a PEG tube. According to the facility's policies and the LPN job description, staff are required to document the date, time, and amount of gastric residual volume (GRV) checks, as well as the administration times of enteral feedings. For the resident in question, physician orders specified a continuous feeding regimen with specific start and stop times. However, documentation inconsistencies were identified: the LPN recorded that the resident's enteral feedings were restarted at a certain time, but subsequent observations and interviews revealed that the feeding pump was off and the tubing was not connected at that time. The LPN later acknowledged that the documentation indicating the feeding had been restarted was inaccurate. Further, when the LPN performed a GRV check and later restarted the resident's enteral feeding, these actions were not documented in the resident's medical record as required. The nurse's notes lacked entries for the actual time the feeding was restarted and for the GRV check, including the date, time, and amount. The DON confirmed that the LPN should have accurately documented all relevant information regarding the resident's enteral feeding and residual checks, in accordance with facility policy and professional standards.
Failure to Post EBP Signage and Ensure PPE Use for Resident with Indwelling Device
Penalty
Summary
The facility failed to implement its infection prevention and control program by not ensuring Enhanced Barrier Precaution (EBP) signage was posted for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, as required by facility policy. Observations on two separate occasions revealed that no EBP signage was present on or around the resident's door or bed, despite physician orders and care plan documentation indicating the need for EBP due to the presence of an indwelling medical device. Staff interviews confirmed the absence of signage and acknowledged that it should have been posted to alert staff and visitors. Additionally, staff did not consistently wear the required personal protective equipment (PPE), specifically gowns, during high-contact care activities for the resident on EBP. Observations showed that an LPN performed PEG tube care and two staff members conducted a transfer using a Hoyer lift without wearing gowns, contrary to facility policy and the resident's care plan. Interviews with the involved staff revealed a lack of awareness that the resident was on EBP and an acknowledgment that gowns should have been worn during these activities. The Assistant Director of Nursing/Infection Preventionist and the Director of Nursing confirmed that EBP signage and appropriate PPE use were required but not followed in these instances.
Lack of Privacy Curtains in Semiprivate Rooms
Penalty
Summary
The facility failed to provide required privacy measures for residents in semiprivate rooms, as evidenced by the absence of ceiling-suspended privacy curtains around the beds of two residents. Observations conducted on multiple occasions revealed that both residents, who were sharing rooms with roommates, did not have the necessary privacy curtains installed to ensure visual privacy. Staff interviews confirmed that these residents were in semiprivate rooms and acknowledged the lack of privacy curtains. The Director of Nursing also confirmed that residents in such rooms should have ceiling-suspended privacy curtains to maintain privacy.
Failure to Ensure Timely Home Health Referral and PEG Tube Supplies at Discharge
Penalty
Summary
The facility failed to ensure that a resident's discharge needs and physician's orders were met prior to discharge. Specifically, there was no documented evidence that a referral to home health was completed and accepted before the resident was discharged, despite a physician's order requiring home health services. The facility was unable to provide documentation that the home health agency had accepted the referral prior to the resident's discharge, and records showed that acceptance did not occur until after the resident had already left the facility. Additionally, the facility did not clarify or fulfill the discharge orders to ensure the resident had all necessary supplies and equipment for PEG tube feeding at home. The resident, who had a PEG tube for nutritional needs and required a specific feeding formula and pump, was discharged without documented orders or arrangements for these essential items. The referral for the PEG tube feeding pump and formula was not made until after discharge, resulting in a delay in the resident receiving the required equipment and nutrition supplies.
Incomplete Transfer/Discharge Documentation for Discharged Residents
Penalty
Summary
The facility failed to complete required transfer or discharge reports for three residents who were discharged or transferred. Record reviews showed that for each of these residents, the transfer/discharge reports were missing critical information such as the chief complaint or reason for transfer, relevant information including detailed instructions for ongoing care, the location to which the resident was transferred or discharged, and a final summary of the resident's status at the time of discharge. The facility's own policy requires that discharge summaries include a recapitulation of the resident's stay, a final summary of the resident's status, and that this information be available for authorized individuals and agencies with appropriate consent. Interviews confirmed that the administrator was aware that the transfer/discharge reports for these residents were incomplete and acknowledged that the reports should have been completed according to policy. The deficiency was identified through both interviews and record reviews, which consistently showed the absence of required documentation for all three sampled residents investigated for transfer and discharge requirements.
Failure to Post Employee Rights Signage
Penalty
Summary
The facility failed to comply with the requirement to post a notice of employees' rights against retaliation for reporting crimes against residents in a conspicuous location. This deficiency was identified through observations, interviews, and record reviews conducted by surveyors. During an inspection of the employee common areas, it was observed that there was no signage displayed regarding employees' rights against retaliation for reporting suspected crimes. This observation was confirmed by multiple staff members, including an LPN, the COO, and the Compliance Executive Nurse, who all indicated a lack of awareness or evidence of such signage. Further interviews revealed that the facility's Administrator was also unaware of the requirement to post this signage. The absence of the required signage was confirmed by the Administrator, who acknowledged that the facility could not provide any evidence of compliance with this requirement. The deficiency highlights a lack of awareness and implementation of policies to ensure employees are informed of their rights against retaliation, as mandated by the United States Social Security Act Title XI, Part A, Section 1150B(d)(3).
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #1 to the State Survey Agency within the required two-hour timeframe. According to the facility's Abuse Investigation and Reporting policy, any alleged violation involving abuse or resulting in serious bodily injury must be reported immediately, but no later than two hours. The incident occurred on February 19, 2025, and was discovered on February 21, 2025, at 9:39 AM. However, the report was not entered into the Statewide Incident Management System until 11:05 AM on the same day. Interviews revealed that the administrator was made aware of the allegation on February 20, 2025, at 9:15 AM, but the discovery date and time were inaccurately documented. The Certified Nursing Assistant involved was suspended pending investigation results. The administrator confirmed the failure to report the allegation within the required timeframe.
Failure to Conduct Timely Performance Review for CNA
Penalty
Summary
The facility failed to conduct a performance review for a Certified Nursing Assistant (CNA), identified as S8CNA, within the required 12-month period. S8CNA was hired on March 10, 2023, and the last documented performance review was dated March 13, 2024. However, there was no evidence of a performance review being completed within the past 12 months. This deficiency was confirmed through interviews with the Human Resources Director and the Administrator, who both acknowledged the absence of the required performance review for S8CNA.
Failure to Document Monthly Weights for a Resident
Penalty
Summary
The facility failed to document monthly weights for a resident, as required by the care plan and facility policy. The resident was supposed to have monthly weight evaluations as per the dietician's recommendations. However, there were no documented weights for November 2024 and December 2024. This lack of documentation was confirmed by the facility's Compliance Executive Nurse, who acknowledged that the policy mandates monthly weight documentation or an explanation for any missing data. The dietitian was unable to assess the resident's three-month weight loss percentage during a nutritional assessment due to the absence of these records.
Failure to Complete and Transmit Discharge MDS
Penalty
Summary
The facility failed to ensure the timely completion and transmission of a Discharge/Transfer Minimum Data Set (MDS) assessment for Resident #66. The resident was admitted to the facility and later transferred to the hospital, after which they were discharged and did not return. Upon review, there was no documented evidence that a transfer and discharge assessment was completed or transmitted for this resident. This deficiency was confirmed through interviews with the LPN responsible for MDS and the Director of Nursing, both acknowledging that the discharge MDS was not completed and transmitted as required.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident. The MDS for this resident, with an assessment reference date of August 1, 2024, incorrectly documented the use of bedrails as a physical restraint, despite the resident being cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. The resident's care plan did not include any documentation regarding the use of restraints, and an observation confirmed that the resident did not have bedrails on her bed. Interviews with the resident and a Licensed Practical Nurse (LPN) confirmed that the MDS was coded in error, and the Director of Nursing (DON) indicated that the facility did not use restraints.
Failure to Conduct Annual Performance Evaluations
Penalty
Summary
The facility failed to conduct annual performance evaluations and provide in-service education based on these evaluations for two Certified Nursing Assistants (CNAs) and one Receptionist. Specifically, there was no documented evidence of annual performance evaluations for S4CNA, S5CNA, and S6Rec, despite their respective hire dates being well before the time of the survey. This deficiency was confirmed through interviews with the Human Resource Director and the Director of Operations, who acknowledged that the evaluations should have been conducted but were not.
Unsafe Mechanical Lift Practices Lead to Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment for residents requiring mechanical lift transfers, resulting in an Immediate Jeopardy situation. Specifically, the staff used mechanical lift slings that were not in good condition for two residents. In one instance, a resident was transferred using a mechanical lift when the sling's strap broke, causing the resident to fall and hit her head, leading to a closed head injury. This incident occurred despite the facility's policy requiring staff to discard any worn, frayed, or ripped slings. In another instance, a different resident was transferred using a mechanical lift sling with altered straps, which had been improperly modified by removing the blue loops. Staff members acknowledged the defect but proceeded with the transfer, contrary to the facility's policy and the manufacturer's instructions. Interviews with staff revealed a lack of adherence to the policy of inspecting and discarding defective slings, contributing to the unsafe conditions.
Latest citations in Louisiana
A resident with Parkinson’s disease, essential tremor, dementia, and legal blindness, who was care planned as being at risk for burns from hot liquids and to receive hot beverages in lidded cups at temperatures not exceeding 130°F, sustained 2nd and 3rd degree burns to the left thigh after spilling coffee during a group activity. The facility’s policy required hot beverages to be cooled to 120–130°F and mandated temperature monitoring, but the coffee served at the time of the incident was reported by dietary staff to be 140°F, and the coffee temperature log did not include documentation for the 10:00 a.m. service when the spill occurred. This failure to adhere to the hot beverage policy and to consistently monitor and document beverage temperatures resulted in actual harm to the resident.
A resident with severe cognitive impairment, multiple chronic conditions, and hospice services required extensive assistance for transfers. During a transfer from wheelchair to bed performed by a CNA, the resident’s left lower leg rubbed against an enabler bar that had a missing end cap, creating a sharp edge. An LPN observed a large laceration on the leg and identified the defective enabler bar as the source of injury. The resident was sent to the ED, where a deep, 25.5 cm stellate laceration required extensive cleaning, internal and external sutures, a tetanus shot, and subsequent daily wound care and antibiotics due to delayed healing. The incident occurred despite facility policies and the Maintenance Supervisor’s responsibilities requiring regular inspection of bed rails and enabler bars for hazards.
The facility did not maintain the required 8 consecutive hours of daily RN coverage on multiple days, as time card records showed that the only scheduled RN worked less than 8 hours on several occasions. The administrator confirmed that this RN was the sole RN scheduled during the period reviewed and acknowledged that full daily RN coverage was not provided on the identified days.
The facility failed to maintain adequate supplies of clean bath towels and bed linens despite its own assessment identifying the need to keep sufficient PAR levels for these items. A resident with a history of traumatic brain injury and another with type 2 DM and asthma, both cognitively intact, reported that towels and linens were often unavailable, with one resident’s family providing personal linens due to frequent shortages. The grievance log documented a complaint about missing personal towels and sheets, and staff, including laundry personnel, a CNA, and the ADON, confirmed that clean towels and bed linens were frequently unavailable during multiple weeks, affecting all residents in the facility.
A resident with severe cognitive impairment, dementia, and multiple comorbidities, assessed as high risk for elopement due to prior exit-seeking and wandering, was found alone outside near the front entrance in a flower bed by an oncoming LPN. The LPN assisted the resident and notified staff inside, and the responsible party later reported the same event. Despite a written wandering and elopement policy requiring notification of regulatory agencies after such incidents, the Administrator acknowledged that this elopement was not reported to the State Survey Agency as required by state law.
A resident with multiple conditions, including type 2 DM, dementia with behavioral symptoms, gait abnormalities, and an anxiety disorder, was documented in progress notes as having eloped and been found outside in a flower bed, and later was found to have a diabetic ulcer on the right heel. Review of the comprehensive care plan showed it was not revised to address either the elopement or the new diabetic ulcer, and the MDS coordinator acknowledged that the care plan should have been updated to reflect these changes in condition.
A resident with type 2 DM, dementia, mobility impairments, and other comorbidities was admitted with a documented deep tissue injury on the right heel, but no corresponding MD wound care orders or treatments were recorded for approximately one month despite a care plan directive to assess for skin breakdown and treat as ordered. A NP note referenced treatment with gentian violet and foam, yet this was not supported by physician orders or the TAR. Later, a wound care nurse identified a diabetic ulcer on the same heel and initiated gentian violet and foam dressings after an order was finally obtained, with treatments documented on only a few dates. The resident was later seen in the ED for cellulitis related to the diabetic heel ulcer and discharged with antibiotics, and both the wound care nurse and NP confirmed gaps in assessment, ordering, and follow-up of the heel wound.
Staff failed to follow infection control protocols during incontinence care for two residents, including not performing required hand hygiene between glove changes and after contact with stool, and placing soiled items on clean linens. CNAs provided perineal care, handled residents’ clean clothing, body surfaces, wheelchairs, and room surfaces, and managed soiled briefs and pads without appropriate glove changes or hand sanitizing, contrary to facility policy. Both CNAs later acknowledged they should have performed hand hygiene and changed gloves correctly, and the DON confirmed that staff are expected to follow these infection prevention practices.
Two residents were not treated in a manner that promoted dignity and quality of life. One resident with left-sided weakness and a flaccid arm following a stroke requested a bedpan, but a CNA told her she was wearing a diaper and could use it instead, despite therapy having recommended bedpan use and the resident not wanting to use a diaper. Another resident with vascular dementia, a history of C. diff enterocolitis, heart failure, and depression, and a moderately impaired BIMS score continued to receive meals on disposable dishware in the dining room even though contact isolation precautions had been discontinued, and nursing leadership confirmed this should not have occurred.
A resident with paraplegia, severe cognitive impairment (BIMS 6), and dependence for mobility and hygiene was repeatedly observed in bed and in a Geri chair without access to a call light, despite facility policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. On multiple occasions throughout the day, the call light was found on the floor or hanging on the side of the bed, out of the resident’s reach. The resident reported being unable to reach the call light, and both a CNA and the DON acknowledged that the call light was not within reach and should have been accessible.
Resident Burn from Overheated Coffee and Failure to Follow Hot Beverage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically related to serving hot beverages. The facility had a written policy titled “Serving Hot Beverages and Soup,” revised in 07/2007, which required the Food Service Department to monitor the temperature of all hot liquids to prevent burns if they contacted skin. The policy specified that coffee should be chilled to 120–130°F before being served and that the Food Service Department was responsible for ensuring all hot beverages, including those for activities, left the kitchen at the proper temperature. However, the coffee temperature log for March only included entries for 6:00 a.m. and 2:00 p.m., with no slot or documentation for 10:00 a.m. coffee temperatures, despite coffee being served at that time. Resident #1 was admitted with diagnoses including Parkinson’s disease, unspecified dementia, essential tremor, and legal blindness. A quarterly MDS with an ARD of 12/31/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and Section GG indicated no functional limitation in upper extremity range of motion. The resident’s care plan included a focus that the resident was at risk for burns from hot liquids, with interventions such as encouraging consumption of hot liquids while sitting at a table, requiring use of a cup with a lid for all hot beverages, and specifying that the temperature of hot liquids should not exceed 130°F. Another care plan focus addressed impaired visual function related to legal blindness, with interventions to provide activities adjusted to the resident’s visual disability. During a 10:00 a.m. group activity, Resident #1 spilled hot coffee on her lap. The dietary manager later confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m., and that the dietary aide who prepared the coffee for the incident reported the coffee temperature as 140°F, which exceeded the facility’s policy limit of 130°F. Resident #1 reported that she spilled coffee on herself while sitting at a table in the activity room and that the coffee was hot and burned when it was spilled. Subsequent nursing and NP assessments documented two in-house–acquired wounds on the resident’s left upper thigh: one described as a blister and one as a burn, later characterized by the NP as a full-thickness (3rd degree) burn and a partial-thickness (2nd degree) burn. These findings, combined with the lack of documented 10:00 a.m. temperature monitoring and the reported serving temperature of 140°F, demonstrate that the facility did not follow its hot beverage policy and failed to protect the resident from an avoidable burn hazard.
Failure to Maintain Safe Enabler Bar Results in Severe Leg Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enabler bar was free from accident hazards, resulting in an actual injury. The facility’s own Bed and Side Rails policy required a designee to inspect all bed frames, mattresses, and bed rails, including grab bars and assist bars, as part of a regular maintenance program. The Maintenance Supervisor job description also required daily tours of the property to identify and correct hazardous conditions and liability hazards. Despite these requirements, the enabler bar on one resident’s bed had a missing end cap, creating a sharp edge that was not identified or corrected prior to use. The affected resident had been admitted with multiple diagnoses, including Peripheral Vascular Disease, Malnutrition, Chronic Kidney Disease, Depression, and Alzheimer’s Disease, and had a BIMS score of 5, indicating severe cognitive impairment. The resident was receiving hospice services and required extensive assistance of one staff person with transfers, as documented in the care plan. On the date of the incident, a CNA assisted the resident with a transfer from a wheelchair to the bed. During this transfer, the resident’s left lower leg rubbed against the enabler bar that had the missing end cap and sharp edge. Nursing documentation recorded that the CNA called an LPN to the room and the LPN observed a large laceration on the resident’s left lower leg with bleeding, which the CNA reported had occurred during the transfer. The LPN noted that the enabler bar had a missing end cap, resulting in a sharp edge, and that the resident’s leg had contacted this area during the transfer. The resident was sent to the emergency department, where records described a very large stellate laceration measuring 25.5 cm on the lateral left lower leg, extending deep to the fascia and requiring extensive cleaning and a complicated repair with internal and external sutures, as well as a tetanus vaccination. Subsequent physician notes documented that the wound required ongoing assessment, daily wound care, and two courses of Bactrim DS due to the extent and depth of the laceration and delayed healing, with sutures removed in stages over several weeks.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for 8 consecutive hours per day, 7 days a week, as required. Review of the time card report for staff member S5RN from 02/22/2026 through 03/24/2026 showed that on five specific dates—02/25/2026, 02/26/2026, 02/27/2026, 02/28/2026, and 03/01/2026—there were fewer than 8 consecutive hours of RN coverage, with recorded work times of 6.50, 7.48, 6.48, 7.50, and 7.50 hours respectively. During an interview on 03/25/2026 at 9:35 a.m., the Administrator (S1) confirmed that S5RN was the only RN scheduled between 02/22/2026 and 03/21/2026 and acknowledged that the facility did not have 8 consecutive hours of RN coverage on the identified dates. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the periods without full RN coverage.
Failure to Maintain Adequate Supply of Clean Towels and Bed Linens
Penalty
Summary
The facility failed to provide residents with a safe, functional, sanitary, and comfortable environment by not ensuring the consistent availability of clean bath towels and bed linens. The facility’s own Facility Assessment Tool, updated on 03/23/2026, identified bed and bath linen as non-medical supplies for which PAR levels must be maintained at all times to ensure adequate supplies. Despite this, multiple interviews and record reviews showed that clean linens and towels were often unavailable. One resident, admitted on 12/05/2022 with diagnoses including diffuse traumatic brain injury and allergic rhinitis and a BIMS score of 15 (no cognitive impairment), reported that bath towels and bed linens were often unavailable, most recently during the week of 03/15/2026 through 03/21/2026. Another resident, admitted on 07/12/2023 with diagnoses including type 2 diabetes mellitus and asthma and a BIMS score of 15, had filed a grievance on 01/10/2026 reporting that personal bath towels and sheets were missing from the laundry and later reported that family had to provide personal linens because the facility frequently lacked bath towels and bed linens. Staff interviews corroborated these reports: a laundry staff member stated the facility frequently did not have clean bath towels and bed linens available for residents; a CNA reported that clean bath towels and bed linens were unavailable for residents during the week of 03/08/2026 through 03/14/2026; and the ADON confirmed that the facility did not have clean bath towels and bed linens available for residents on 03/23/2026. This pattern of unavailability affected the facility’s census of 58 residents.
Failure to Report Resident Elopement to State Survey Agency
Penalty
Summary
The deficiency involves the facility’s failure to report a resident elopement to the State Survey Agency as required by state law and by the facility’s own Wandering and Elopement Policy dated 11/15/2023. That policy directs that when a resident returns after an elopement, the DON or charge nurse must examine the resident, notify the attending physician, complete an incident/accident report, document the event in the medical record, and notify regulatory agencies per state guidelines. Record review showed that one resident, admitted on 01/09/2026, had multiple diagnoses including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with anxiety, psychotic and mood disturbance, anxiety disorder, and essential hypertension. A Quarterly MDS documented a BIMS score of 4, indicating severely impaired cognition, and the resident was assessed as an elopement risk level 3 due to a history of attempted elopement at home, wandering with purpose in the facility, and exit-seeking behavior. Progress notes and interviews confirmed that on 02/08/2026 the resident was found outside the facility alone in the flower bed at the front of the building, bent over with hands in the dirt, by an oncoming nurse arriving for her shift. The LPN reported she parked her car, went to assist the resident, and alerted staff inside that the resident was outside alone. The resident’s responsible party similarly reported that the resident had been found outside alone in front of the facility on that date. During interview, the Administrator confirmed that the resident, who had dementia and a BIMS score of 4, had been found outside in the flower bed in front of the facility and acknowledged that this incident was not reported to the State Survey Agency, constituting a failure to report the elopement in accordance with state law and facility policy.
Failure to Revise Care Plan After Elopement and Development of Diabetic Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive care plan following significant changes in condition, specifically an elopement and the development of a diabetic ulcer. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy at multiple sites, gait and mobility abnormalities, disorientation, unspecified dementia with associated anxiety, psychotic and mood disturbances, an anxiety disorder, and essential hypertension. Progress notes documented that the resident was found outside the facility in a flower bed, bent over with hands in the dirt, after having eloped from the building. Further review of the resident’s progress notes showed that a diabetic ulcer was identified on the resident’s right heel the day after the elopement. Despite these documented changes in condition, review of the resident’s comprehensive care plan revealed no revisions to address the actual elopement event or the new diabetic ulcer on the right heel. During an interview, the MDS Coordinator confirmed that the resident’s care plan should have been revised to reflect both the elopement and the development of the diabetic ulcer, but it was not.
Failure to Implement and Document Diabetic Foot and Heel Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for a resident with diabetes and multiple comorbidities. The resident was admitted with type 2 diabetes mellitus, cognitive communication deficit, aphasia, muscle wasting and atrophy, gait and mobility abnormalities, disorientation, unspecified dementia with associated psychiatric symptoms, anxiety disorder, and hypertension. On admission, the Minimum Data Set and skin assessment documented a deep tissue injury on the right heel. A nurse practitioner’s progress note dated shortly after admission described a deep tissue injury on the right heel being treated with gentian violet and foam and noted the heel was tender to touch. However, there were no corresponding physician’s orders for wound care treatment on the January and early February physician order sheets, and the treatment administration records for that same period showed no wound care treatments provided. The resident’s care plan for diabetes included an approach to check the body for breaks in the skin and treat promptly as ordered by the physician, but the facility did not develop and implement specific approaches addressing the documented right heel injury. A wound care nurse’s progress note later identified a diabetic ulcer on the right heel, described as tender and spongy, and documented application of gentian violet–soaked gauze and foam dressing. Only then was a physician’s order written to monitor the right heel and apply gentian violet dampened gauze and a protective dressing on specified days, with the treatment administration record showing documentation of these treatments on only three dates. The resident’s responsible party reported that the resident was discharged and subsequently required emergency department treatment for cellulitis due to a diabetic ulcer on the right heel, for which antibiotics were prescribed. The wound care nurse confirmed the initial documentation of a deep tissue injury without any physician’s orders for treatment and that the diabetic ulcer was not identified until nearly a month after admission, and the nurse practitioner confirmed he examined the right heel only once during that period.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program during incontinence care, specifically related to hand hygiene, glove use, and handling of soiled linens. The facility’s own policy for bladder incontinence care requires staff to perform handwashing or use alcohol gel, don disposable gloves, cleanse the perineal and anal areas, then remove and discard gloves and perform hand hygiene before proceeding. During observed incontinence care for one resident, a CNA donned clean gloves and used perineal wipes to remove bowel movement from the resident’s buttocks, then, without changing gloves or performing hand hygiene, placed a clean incontinence pad and brief under the resident. The CNA placed a soiled brief and urine-soaked bed pad at the foot of the bed on top of the resident’s clean comforter, then disposed of the soiled brief in the trash, spread a clean incontinence pad on the bed, and secured a clean brief, all without changing gloves or performing hand hygiene. The same CNA continued to touch the resident’s clean clothing, body, wheelchair armrests, and room door, transferred the resident to the wheelchair, and moved the resident into the hallway, then returned to retrieve the soiled incontinence pad and carried it down the hall to the soiled linen barrel before finally disposing of gloves, again without any observed hand hygiene during the entire episode of care. In a separate observation involving another resident, two CNAs provided incontinence care without performing hand hygiene before donning gloves. One CNA removed bowel movement from the resident’s buttocks, discarded the soiled brief, removed soiled gloves, and donned clean gloves without hand hygiene, then touched the resident’s extremities, bed linens, and applied a clean brief and incontinence pad. The CNA again changed gloves and dressed the resident in a clean gown, touching multiple body areas, without hand hygiene. The second CNA unfastened the brief, confirmed the resident remained soiled, wiped remaining stool, and helped secure the clean brief without changing soiled gloves or performing hand hygiene. Both CNAs later confirmed in interviews that they should have performed hand hygiene and changed gloves appropriately, and the DON confirmed staff are expected to change gloves when soiled or moving from contaminated to clean areas, sanitize hands between glove changes and between residents, and avoid placing soiled linen on clean linen.
Failure to Honor Resident Dignity and Discontinue Unnecessary Isolation Practices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and self-determination. One resident, who was lying in bed and requested a bedpan, was observed on 03/25/2026 at 8:59 a.m. using the call light with surveyor assistance. When the CNA entered the room, she stated the resident was wearing a diaper, could not get up due to left-sided weakness from a stroke, and said the resident "can go in her diaper" instead of providing a bedpan as requested. A COTA later reported that therapy had recommended the resident use a bedpan and had removed the bedside commode the previous day, and that the resident did not want to use a diaper. The COTA also stated the resident’s left arm was flaccid and that she required maximum assistance of two people. A second deficiency involved another resident who continued to receive meals on disposable dishware in the dining room after contact isolation precautions had been discontinued. This resident had diagnoses including vascular dementia, enterocolitis due to Clostridium difficile, hyperlipidemia, heart failure, and depression, and had a BIMS score of 9, indicating moderately impaired cognition. A physician order for single room isolation with contact precautions had been discontinued on 02/17/2026, yet on 03/23/2026 at 11:20 a.m., the resident was observed receiving a lunch tray on disposable dishware while seated in the dining room. The ADON confirmed the resident was no longer on contact precautions and should not have been receiving meals on disposable dishware.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was accessible as required by facility policy and necessary to reasonably accommodate the resident’s needs. The facility’s policy on answering call lights, dated 01/16/2026, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. Resident #3 was admitted on 12/07/2023 with diagnoses including mononeural disorder, paraplegia, epilepsy, and peripheral vascular disease. A quarterly MDS with an ARD of 03/03/2026 documented a BIMS score of 6, indicating severe cognitive impairment, and showed the resident required setup assistance with eating, was dependent for toileting and personal hygiene, and needed substantial/maximal assistance to roll left to right. On multiple observations on 03/24/2026, surveyors found the resident’s call bell out of reach despite the resident’s reliance on it to express needs. At 10:12 a.m., the resident was lying in bed with eyes closed and the call bell was on the floor on the right side of the bed, not within reach. At 12:24 p.m., the resident was awake and alert in bed, and again the call bell was on the floor and not reachable; the resident stated he could not reach it. During an interview at 12:45 p.m., a CNA familiar with the resident confirmed the resident could express needs with short responses and used the call bell. At 12:48 p.m., with the CNA present, the call bell was still on the floor and not within reach, and the CNA acknowledged it should have been accessible. Later observations at 1:41 p.m. and 3:00 p.m. found the resident awake and alert in a reclined position in a Geri chair, with the call bell hanging on the side of the bed and again out of reach; the DON, present at 3:00 p.m., confirmed the call bell was not within reach and should have been.
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